This invention relates generally to a system and method for online selection of healthcare services and, more particularly, to a system and method for allowing a user to select a customized healthcare services panel and for providing the user with a healthcare services package, the cost of which is calculated based on the user""s selections.
The majority of healthcare in the United States is sponsored by employers, because, unlike most of its European counterparts, the United States does not automatically provide healthcare services on a no-cost basis to all of its citizens. Generally, an employer selects and contracts with a third party administrator to administer its health benefits program funded either by the employer buying insurance or by self-funding the program (self-insurance).
Historically, employers sponsored xe2x80x9cTraditional Indemnityxe2x80x9d programs where employees and their dependents were free to choose and utilize the services of any healthcare service provider and be reimbursed for covered benefits, less some form of cost sharing such as an annual deductible or co-insurance. For example, a covered employee was responsible for the first $100 in annual covered benefits (xe2x80x9cdeductiblexe2x80x9d), for 20% of the next $5,000 (i.e., a $1,000 annual co-insurance limit), and was fully reimbursed for the amount that the year""s claims exceed $5,000. Because the employee was paying only a minority of the cost of healthcare services, the employee was not sensitive to the cost and healthcare service providers rarely competed on the basis of price. However, healthcare service providers did compete based on other attributes such as technology, and the advent of expensive new technologies further drove costs upward and resulted in the cost of employers"" healthcare programs spiraling sharply upward in the 1980s and early 1990s.
In response to the rapidly rising costs of their healthcare programs, employers have increasingly turned to Managed Care Organizations (xe2x80x9cMCOsxe2x80x9d) such as Health Maintenance Organizations (xe2x80x9cHMOsxe2x80x9d) and Preferred Provider Organizations (xe2x80x9cPPOsxe2x80x9d). MCOs develop restricted networks of healthcare service providers who are willing to accept a negotiated level of reimbursement which is typically much lower than the provider""s standard fees. Because the employer (and not the employee/dependent) is the customer of the MCO, the employee/dependent has virtually no voice in the selection of the MCO""s provider network. Employees who go outside the MCO""s provider network typically receive no benefits from traditional HMOs and typically receive dramatically reduced benefits from PPOs or xe2x80x9cPoint of Servicexe2x80x9d HMO programs.
MCOs have also implemented extensive programs designed to further manage the cost of healthcare. Most of these Utilization Management (xe2x80x9cUMxe2x80x9d) programs are designed to reduce utilization and restrict the delivery of care. Examples of UM programs include precertification programs which require prior authorization from the MCO before a physician can refer a patient to another physician, order a procedure or test or admit a patient to a hospital. Some MCO programs require that a Primary Care Physician (xe2x80x9cPCPxe2x80x9d) be selected by each covered member, and that the PCP must act as a xe2x80x9cgatekeeperxe2x80x9d to authorize referrals to other physicians.
MCOs also rely heavily on the collection of utilization and claim information in order to administer their programs and to manage the risk associated with healthcare costs. MCOs utilize a variety of methodologies to manage the risk, including both risk sharing and risk transfer to healthcare service providers. Some of the MCO risk sharing and risk transfer methodologies have become quite controversial and have therefore become subject to increased scrutiny, e.g., placing a physician at risk for the cost of his referrals of patients to specialists or hospitals.
In light of the above, it is not surprising that MCO""s chosen by and designed for employers are generally ill-favored by both employees and healthcare service providers. Unfortunately, the reality is that healthcare coverage is a business-to-business product in the United States, and not a consumer product. Employee dissatisfaction generally stems from the following shortcomings of the MCO programs: (1) the limited provider network may not include their desired physician or hospital; (2) the administrative and utilization management requirements of the program are often burdensome and frustrating; and (3) the benefit design chosen by the employer often does not meet the particular needs of the employee.
Physicians, hospitals and other healthcare service providers are generally discontent with MCOs because: (1) the administrative costs and paperwork are unduly burdensome; (2) the UM programs imposed by MCOs are both administratively cumbersome and expensive; and (3) the provider contracts offered by MCOs allows the MCO to unilaterally dictate the price, terms, and administrative requirements; and (4) the profits and administrative fees charged by MCOs is believed to be at the expense of patient care.
Ideally, healthcare service providers should be able to contract more directly with patients and employers, thereby reducing the role of intermediaries such as MCOs. Furthermore, employees and their families should be able to be xe2x80x9cconsumersxe2x80x9d and make their healthcare purchasing decisions. Finally, employers should be afforded relief from both unpredictable and rising increases in their costs of sponsoring healthcare programs for their employees.
Accordingly, a need exists for a healthcare coverage system and method that allows individuals to contract for the healthcare services that they need, from the healthcare providers that they prefer, and at a price that is within their financial restraints. In other words, to empower the individual as a consumer. There further exists a need to implement Web sites on the Internet to reduce the administration costs of implementing such a healthcare coverage system and to facilitate the registration of individual members into the system. Finally, there exists the need to provide a mechanism that allows healthcare service providers to offer their services to consumers who seek to build a customized healthcare services package, while providing the healthcare service providers stable and predictable fixed monthly incomes and manageable patient lists.
In connection with the foregoing, a method and system is disclosed for allowing a user to select healthcare services where a server generally receives personal information data comprising a user identifier and a financial parameter from the user, provides a list comprising a plurality of healthcare service providers to the user, receives a selection of a healthcare services panel from the user comprising at least one of the healthcare service providers, determines a healthcare services package based on the user""s selection and the financial parameter and provides the determined healthcare services package to the user for selection of the healthcare services package.
According to one aspect of the invention, the personal information data further comprises a sponsor identifier that identifies the party responsible for paying for all or a portion of the user""s healthcare benefits, such as an employer of the user, a healthcare administration company (xe2x80x9cHACxe2x80x9d) associated with the user (e.g., an insurance company, HMO, or Third Party Administrator), or the user himself.
According to another aspect of the invention, the financial parameter comprises an amount of healthcare benefits available from the employer or the HAC, or an amount of healthcare costs identified by the user.
According to another aspect of the invention, the financial parameter represents that the user is soliciting price estimates.
According to another aspect of the invention, the server receives a selection of an anchor provider by the user, and wherein the list is provided to the user based on the anchor provider.
According to another aspect of the invention, the list is provided to the user based on a predefined criteria or a predefined criteria associated with the anchor provider.
According to another aspect of the invention, the predefined criteria comprises one of the group consisting of: price, quality, ratings, ranking, location, time, distance and hospital affiliation.
According to yet another aspect of the invention, the personal information data further comprises an identification of a plurality of individuals to be associated with the healthcare services package.
According to yet another aspect of the invention, a healthcare services panel is selected by the user for each of the plurality of individuals, and wherein the healthcare services package is further determined based on the healthcare services panels.
According to yet another aspect of the invention, each healthcare service provider is associated with an individual cost (xe2x80x9cICxe2x80x9d) and an umbrella policy credit (xe2x80x9cUPCxe2x80x9d) and the personal information data further comprises an uncredited umbrella policy cost, and wherein the determination of the healthcare services package comprises aggregating the ICs and UPCs of the healthcare service providers on the healthcare services panel, calculating the difference between the uncredited umbrella policy cost and the aggregated amount of the UPCs, wherein the difference represents a credited umbrella policy cost, and determining the healthcare services package based on the sum of the aggregated ICs and the credited umbrella policy.
According to yet another aspect of the invention, the ICs and UPCs of each healthcare service provider of the healthcare services panels of each of a plurality of individuals are aggregated, the difference between the uncredited umbrella policy cost and the aggregated amount of the UPCs of each of a plurality of individuals is calculated, wherein the difference represents a credited umbrella policy cost, and the healthcare services package is determined based on the sum of the aggregated ICs and the credited umbrella policy cost.
According to yet another aspect of the invention, the determination of the healthcare services package is further based on an amount of deductible on an umbrella policy included in the personal information data.
According to yet another aspect of the invention, an amount of deductible on an umbrella policy is included in the personal information data for each individual.
According to yet another aspect of the invention, the server generally receives from the healthcare service provider information data comprising a provider identifier and a rate parameter, provides the information data to a plurality of users for selection by the users, provides a list to the healthcare service provider comprising the plurality of users that selected the healthcare provider, and provides payment to the healthcare service provider based on the rate parameter.
According to yet another aspect of the invention, the information data further comprises a location and a hospital affiliation of the healthcare service provider, an identification of services included in the rate parameter and/or a referral panel.
According to yet another aspect of the invention, the rate parameter comprises a fixed rate and at least one amount of co-payment.